Prepectoral breast reconstruction has been shown to confer excellent cosmetic and functional outcomes in select patients. However, the cost per reconstructed breast is high when anterior or complete ADM coverage of the implant is used. The technique described in this article utilizes a vicryl mesh pocket and ADM sling to control the implant position, selectively applies ADM to inferolateral support where it is needed long term, and lowers the cost per reconstruction. ADM cost varies between institutions and type of ADM used. However, instead of using 2 sheets of ADM as in complete ADM coverage of prepectoral implants, we use 1 sheet. Therefore, the cost is cut in half.
This technique is designed for direct-to-implant reconstruction in the prepectoral plane. For direct-to-implant breast reconstruction, a robust skin flap is critical, even more important in prepectoral breast reconstruction. The importance of the skin flap has been emphasized in other case series of prepectoral breast reconstruction and in our own series.8,11 In patients with very challenged skin flaps, direct-to-implant or prepectoral breast reconstruction would not be recommended, in which case we would recommend placement of a deflated or minimally filled tissue expander either total or partially under muscle with ADM coverage.
One can adopt this technique for tissue expander placement in patients with robust skin flaps, but the prosthesis cannot be squeezed into the sleeve as we show here.
Modifications of this technique could include ADM inset with the sizer in place, a variation in technique the senior author used to prefer. However, over the decade, as the senior author gained experience in direct-to-implant placement, it became less or unnecessary to keep the sizer in place during inset of the vicryl/ADM sleeve or ADM in general. Technically, it became very expeditious to suture the ADM to the pocket when the sizer is removed, especially in patients with smaller breasts or when the inframammary incision was short. The ADM fits well contoured along the inframammary fold, and we have not had problems with contouring. However, it is certainly possible to suture the ADM in place with the sizer in the pocket, which may allow for improved visualization of contour before insertion, or test the contour after inset with the sizer. This is left to preferences and experience of the surgeon.
It is further possible to perform this technique with vicryl mesh only. However, inferolateral ADM provides support to the implant and prohibits migration downward or laterally until a capsule is formed. ADM further helps prevent implant rippling in patients at risk (limited preoperative soft-tissue envelopes, thin mastectomy flaps, and small-volume implant reconstructions).11
This article is intended to be a description of surgical technique. We previously published our clinical outcomes experience in PRS Go.11 In this series, 23 breasts underwent prepectoral breast reconstruction over a period of 18 months. None of the 13 patients had breast animation deformity postoperatively. There was 1 early hematoma requiring operative intervention. One morbidly obese patient undergoing chemotherapy using a nearby chest port ultimately experienced infection requiring implant removal. Three patients developed small seromas that resolved uneventfully. One patient demonstrated implant rippling postoperatively but did not seek revision. There were no instances of implant extrusion or skin flap necrosis requiring operative intervention. No instances of implant malposition developed, as the vicryl mesh is folded neatly posterior to the implant. It is contained in the vicryl/ADM pocket and should not move.
There has been no bunching of excess vicryl mesh, as this is folded neatly posterior to the implant, and no excess material remains anterior. The excess posterior material is not noticeable on the operating room table nor postoperatively. The vicryl hydrolyzes over 2 months and is not palpable long term.
Long-term follow-up is needed to understand the risk of capsular contracture in prepectoral breast reconstruction and to determine the role of prepectoral breast reconstruction in patients who require postmastectomy radiation therapy.
The technique described in this article utilizes a vicryl mesh pocket and ADM to control the implant position. It selectively applies ADM to provide inferolateral support where it is needed long term, and lowers the cost per reconstruction. Short-term results are promising. Long-term data are currently being acquired to confirm initial results.
1. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014;133:496–506.
2. Smith BL, Tang R, Rai U, et al. Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 2017;225:361–365.
3. Spear SL, Sher SR, Al-Attar A. Focus on technique: supporting the soft-tissue envelope in breast reconstruction. Plast Reconstr Surg. 2012;130:89S–94S.
4. Tessler O, Reish RG, Maman DY, et al. Beyond biologics: absorbable mesh as a low-cost, low-complication sling for implant-based breast reconstruction. Plast Reconstr Surg. 2014;133:90e–99e. doi: 10.1097/01.prs.0000437253.55457.63.
5. Rodriguez-Unda N, Leiva S, Cheng HT, et al. Low incidence of complications using polyglactin 910 (vicryl) mesh in breast reconstruction: a systematic review. J Plast Reconstr Aesthet Surg. 2015;68:1543–1549.
6. Scarfì A, Ordemann K, Hüter J. Reconstruction of an ablated breast. Eur J Gynaecol Oncol. 1986;7:93–96.
7. Gruber RP, Kahn RA, Lash H, et al. Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg. 1981;67:312–317.
8. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast reconstruction: rationale, indications, and preliminary results. Plast Reconstr Surg. 2017;139:287–294.
9. Bernini M, Calabrese C, Cecconi L, et al. Subcutaneous direct-to-implant breast reconstruction: surgical, functional, and aesthetic results after long-term follow-up. Plast Reconstr Surg Glob Open. 2015;3:e574.
10. Sbitany H, Piper M, Lentz R. Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple sparing mastectomy. Plast Reconstr Surg. 2017;140(3):432–443.Sep;
11. Kobraei EM, Cauley R, Gadd M, et al. Avoiding breast animation deformity with pectoralis-sparing subcutaneous direct-to-implant breast reconstruction. Plast Reconstr Surg Glob Open. 2016;4:e708.
12. Nadeem R. Prepectoral implant-based breast reconstruction; complete acellular dermal matrix wrap or anterior circumferential cover. Breast J. 2018 Mar;24(2):223–224.
13. Vidya R. Prepectoral breast reconstruction or muscle-sparing technique with the Braxon porcine acellular dermal matrix. Plast Reconstr Surg Glob Open. 2017;5:e1364.
14. Jansen LA, Macadam SA. The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part II. A cost analysis. Plast Reconstr Surg. 2011;127:2245–2254.
15. Cauley RP, Liao EC. Deepithelialization and extended dermal apposition: a technique for closure of high-risk incisions in breast reconstruction. Plast Reconstr Surg Glob Open. 2016;4:e802.